Dear Editor,
Guyana’s chief psychiatrist most recently called for the integration of mental health into primary care. The Draft Mental Health Strategy of Guyana 2015-2020 confirmed “minimal numbers of general health human resources with the necessary mental health competencies to provide mental health services at any level of general health care”. Also, “there are no national or institutional standards for mental health care, facilities or human resources”. Given the scarcity of psychiatrists, psychologists, social workers, psychiatric nurses and other mental health professionals, The Caribbean Voice (TCV) backs the call for integration to be implemented using the Sri Lanka Project, a training programme for primary care.
We know from government figures included in the Draft Mental Health Strategy 2015-2020 that 10 to 15% of Guyanese suffer from a mental disorder at any one time. This means that 78,000 to 114,500 Guyanese are suffering from a mental disorder and require some level of mental health care service with 3 to 5% of the population having a severe chronic mental disorder. Approximately 20,000 Guyanese suffer from severe mental illness with unipolar depression as the fifth greatest contributor to disease burden in Guyana. Suicide is the leading cause of death with the Guyanese rate being 44 per 100,000. These figures do not include people with epilepsy,
mental retardation and alcohol abuse.
The Guyana government’s stated aim is mental health for all. Given the prevalence of mental health rates and demands with minimal available resources as described, it is essential to integrate mental health into primary care to ensure the general population has equitable access.
The Sri Lanka Project was based on an endeavour to establish a systematic ‘Train the Trainers’ programme. This programme was funded by the World Psychiatric Association (WPA) and we urge the government to explore possible funding from this organization as a means of achieving integration. In Sri Lanka the WPA allocated funding to train 155 trainers in order to equip the trainers to roll out the mental health training on a continuous basis.
Sri Lanka and Guyana have similar and parallel health care structures. Sri Lanka had very high suicide rates, mental health needs and a government funded health system that was decentralised with funding by central government and locally by provincial councils, the Guyana equivalent of regional health authorities. There was approximately one psychiatric consultant per 500,000 people, no specialized psychiatric nurses and very few psychologists, occupational therapists and
psycho-social workers as in Guyana. Estimating the expenditure on mental health services was not possible since mental health expenditures were integrated within the general health budget. Mental health facilities include one psychiatric hospital, psychiatric beds in general hospitals, outpatients departments and community facilities as in Guyana.
The Sri Lanka project aimed at integration through a Train the Trainers programme with the Sri Lanka Ministry of Health working collaboratively with the National Institute of Mental Health and the WPA. People were specifically selected from each region of the country based on their ability to roll out the training to others. Criteria for selection included psychiatrists, medical officers with mental health experience and other mental health professionals who were able to commit time to the subsequent roll-out of the training programme to primary care staff.
The Sri Lanka project delivered training to 45 psychiatrists, 110 medical officers of mental health and 95 registered medical practitioners through five courses in different regions of the country. Due to the scarcity of mental health professionals in Guyana TCV would advocate that the criteria for selection be expanded to include religious leaders, teachers, police, social workers, child protection officers and other relevant and appropriate people. Guyana has administrative regions and regional health authorities under the control of the Ministry of Health and links with NGOs that can be involved and assist with the planning, organising and delivery of the training programme.
Also, the Sri Lanka project for primary care staff was a five-day course over forty hours, which covered five modules. The first module focused on mental health and mental disorders and their contribution to physical health and economic and social outcomes. The second module covered communication skills, assessment, mental state examination, diagnosis and management, managing difficult cases, management of violence and breaking bad news. The third module encompassed neurological disorders, epilepsy, Parkinson’s disease, headache, dementia and toxic confusional states. The fourth module covered psychiatric disorders based on the WHO primary care guidelines for mental health. The fifth module focused on health and other sector system issues of policy, legislation, links between mental health, reproductive health, HIV and
malaria, roles and responsibilities, health management information systems, working with community health workers and with traditional healers and integration of mental health into operational plans. TCV believes the modules and core concepts of the training programme are relevant to Guyana and would recommend the training in its current form. However, we understand that changes may be required in the context of Guyana to include social and cultural differences and an understanding of suicide ‒ its causes, impact and preventative measures.
The course was dynamic and taught through theory, practice, role-plays, discussions and WPA videos on depression, psychosis and somatisation. The emphasis of the course was for primary care staff and others to acquire practical skills and competencies for assessment, diagnosis and management. Participants had to complete 25 supervised role-plays on different topics over the week and to observe and comment on 25 role-plays conducted by others. Each participant was given both a hard copy print out and a CD of the guidelines plus all the teaching slides, role-plays and teacher’s guide.
TCV firmly believes that the implementation of the Sri Lanka type project can have impact on two fronts. It can contribute to the development of national and institutional standards for mental health care in Guyana and underpin the government’s realisation of mental health care for all.
Yours faithfully,
Devina Samaroo
The Caribbean Voice
